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A 34 year old man who drowned in Gloucester Docks almost a year ago had been a frequent “rollercoaster” caller to police and the ambulance service, an inquest heard.

Ashley Simmonds, of Norfolk Street, Gloucester, was found dead in the Victoria Basin last April - three days after he had called police saying he could hear voices and that he wanted to jump into the water.

The Gloucestershire Coroner Katie Skerrett recorded a conclusion that his death was accidental and he had not intended to commit suicide.

Ashley Simmonds

The coroner had heard that Ashley called the emergency services more than 200 times in the months before his death.

In the wake of the tragedy, an Independent Office of Police Conduct (IOPC) investigation was held into the way police handled calls from Ashley on April 10, the day he is believed to have gone into the Docks.

"Rollercoaster patient"

Coroner Skerrett heard Ashley had called police and ambulance so often in the past that a protocol had been put in place which was flagged up on their systems every time he called.

The protocol was understood by everyone who had access to it, the inquest heard.

He had also been given an 'acceptable behaviour contract' to try to solve the issue of him frequently calling emergency services.

The Victoria Basin at Gloucester Docks (Image: Ed Stilliard)

Susan Stanway, a senior nurse who deal with frequent caller issues, said: “Ashley was a rollercoaster patient – there was a substantial increase in the number of calls he made in the months before his death."

On April 10 he had called police saying he could hear voices, had taken an overdose of amphetamines, that he had self harmed and that he wanted to jump into the docks, the inquest was told.

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An ambulance crew were sent to find Ashley and could not do so, despite him living quite close to the docks.

His body was found a few days later under a gangway close to McColls in the Docks.

The inquest heard from Ashley’s consultant Dr Amjad Uppal that he suffered from an emotionally unstable personality disorder and had problems with taking illicit substances which made the condition worse.

Gloucestershire Coroner's Court in Gloucester

"This is sad for all of us"

However, before his death he was doing well and getting on well with the mental health team.

“He struggled with praise,” said Dr Uppal, “but we felt independent living was good for him.

“His relationship with everyone involved in his care was good and this is sad for all of us.”

When his body was recovered from the Docks a post mortem found he had had died from freshwater drowning and his body had been in the water for between 48-72 hours. A number of drugs were found in his system but not to a level which would have killed him, the inquest heard.

Ashley’s family did not attend Thursday’s inquest.

The coroner recorded a conclusion of accidental death saying there was no note and no evidence he had intended to kill himself.

“That he left no note suggests he did not intend to kill himself," she said.

“The amount of alcohol in his system showed he would have been less able to resist the tragic outcome.

“It is very clear there was a clear package of care in place for Ashley and the ambulance crew who attended would not have been able to find him because he was already in the water.”

Where to get help and what to do if you're worried about mental health issues

What to do if you feel low

If you're not feeling yourself, going through a bad time, or are just feeling sad more than usual, it's possible that you could be experiencing depression or anxiety.

This doesn't mean that you're necessarily at risk, there are scales of both, and it could be that you are just experiencing low mood or moderate anxiety.

The most important thing to do is to let people around you know how you're feeling.

Talking to a partner, family member or friend is essential. They may be able to offer support and can be there for you while you go through a difficult time.

Where can I get help?

You should also go to talk to your GP.

Your GP can help find out if you're experiencing anxiety, stress and depression.

They can recommend ways to feel better naturally, for example increasing your exercise levels, or can suggest medication and counselling.

They can also refer you on to other mental health services.

Who else can I call?

Let’s Talk is a free NHS service for anyone experiencing mental health issues such as anxiety, stress and depression. It can be contacted on 0800 073 2200 or via www.talk2gether.nhs.uk.

If you feel you need more help, you can call the Gloucestershire Health and Care NHS Foundation Trust direct on 0800 073 2200 to discuss an appointment.

The mental health charity Mind runs a helpline on 0300 123 3393, or 86463 on text.

The Samaritans is also always there for those who have nowhere else to turn.

But it stresses that it's not just for those who have suicidal thoughts. In fact they say: "Most people who contact us are not suicidal. When you talk to us, we will give you an opportunity to talk about any thoughts or feelings you have, whatever they may be."

You can call the Samaritans on 116 123.

In Cheltenham, the Suicide Crisis Centre provides vital support. Along with the services at the centre in High Street, Cheltenham, the charity also goes out to visit service users – sometimes staying for hours at a time if they are at high risk of suicide.

After the inquest the Independent Office for Police Conduct issued a statement saying it has identified how Gloucestershire Constabulary 'can improve plans to support people with mental health concerns who make frequent calls to the force.'

IOPC Regional Director Derrick Campbell said: “The death of Ashley Simmonds has highlighted that even when authorities have a specific plan in place to help a vulnerable individual tragedies can occur.

“Our investigation identified ways in which the force could improve the preparation of plans to help the most vulnerable in society.”

The IOPC Statement in full

The IOPC statement said: "Our investigation was launched following the death of Mr Simmonds, a vulnerable man who was well known to emergency and social services.

"Mr Simmonds made a number of calls to Gloucestershire Constabulary on 10 April, 2017 reporting that he was planning on self-harming. He was reported missing the following day by his care worker and his body was found in Gloucester Docks on April 13.

"Our investigation looked at the agreed protocols in place between Gloucestershire Constabulary and South Western Ambulance Service (SWASFT) and whether these were followed on 10 April.

"A ‘Trigger Plan’ to support Mr Simmonds had been agreed between the force, SWASFT and 2Gether NHS Foundation Trust in December 2016.

"As part of the plan, when Mr Simmonds called the police he was aimed towards community mental health services unless there was an obvious risk to members of the public or he was clearly in need of emergency medical attention.

"Our investigation identified how the force could improve similar plans in the future which has been accepted by Gloucestershire Constabulary.

"The mental health lead will ensure plans should include the authors of the plan, the date of its implementation and the next review date

"Trigger plans should include clear mandatory actions, but also wording that recognises that each situation is different and threat and risk will need to be assessed so a flexible response can be made.

"Our investigation found no indication any officer or employee within the force had breached standards of professional performance on 10 April."